DA Form 5028-R Medcase Support and Transmittal Form (Lra)

DA Form 5028-R - also known as the "Medcase Support And Transmittal Form (lra)" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5028-R - was last revised on July 1, 1997. Download an up-to-date fillable PDF version of the DA 5028-R down below or look it up on the Army Publishing Directorate website.

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MEDCASE SUPPORT AND TRANSMITTAL FORM
For use of this form, see SB 8-75 MEDCASE; the proponent agency is the OTSG
1. ACTIVITY
2. ASSET CONTROL NUMBER
EQUIPMENT MAINTENANCE ACTIVITY
3. DO YOU SEE PROBLEMS WITH PROVIDING MAINTENANCE SUPPORT? (If Yes, explain)
YES
NO
4. MAINTENANCE WILL BE PROVIDED
5. ANNUAL MAINTENANCE COST
6. TRAINING TYPE
IN-HOUSE
SERVICE CONTRACT
NONE
ONE TIME
RECURRING
7. REPLACED ITEM WITH MAKE AND MODEL
10. MCEL COST
11. EXPENDED COST
8. LIFE EXPECTANCY (Years)
9. DATE IN SERVICE (YYYYMM)
12. EQUIPMENT AND INSTALLATION CHARACTERISTICS
13. THE JUSTIFICATION PROVIDED HAS BEEN REVIEWED
AND THE STATEMENTS REGARDING MAINTENANCE
ROUTINE
REQUIRES INSTALLATION
COMPLEX
HAV E BEEN VERIFIED.
REQUIRES TURNKEY INSTALLATION
THE REPLACEMENT OF THE ITEM
IS
EXISTING EQUIPMENT REQUIRES DE-INSTALLATION
IS NOT SUPPORTED
ADDITIONAL ELECTRICAL SUPPORT OR EMERGENCY POWER
BASED UPON MAINTENANCE CONSIDERATIONS.
14. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
15. SIGNATURE
ENGINEER (Health Facility Project Officer for BLIC NF & MB)
16. ARE SITE MODIFICATIONS, UTILITIES OR
17. ESTIMATED SITE PREPARATION COSTS
18. WITHIN THE SCOPE OF THE
OTHER COSTS INVOLVED?
PROJECT (BLIC NF OR MB)?
YES
NO
YES
NO
19. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
20. SIGNATURE
INFORMATION MANAGEMENT OFFICER
21. I HAVE REVIEWED THIS DOCUMENT AND RECOMMEND
APPROVAL
DISAPPROVAL
N/A
22. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
23. SIGNATURE
RESOURCES MANAGEMENT OFFICER
24. NON-MEDCASE COSTS ASSOCIATED WITH THIS REQUIREMENT ARE
25. THE ECONOMIC CONSIDERATIONS CITED
WITHIN CURRENT OR ANTICIPATED RESOURCES OF THIS ACTIVITY?
(In Justification) HAVE BEEN VERIFIED AND ARE
ACCURATE?
YES
NO
YES
NO
26. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
27. SIGNATURE
RADIOLOGY REVIEW
28. I HAVE REVIEWED THIS DOCUMENT AND RECOMMEND (Comments attached)
APPROVAL
DISAPPROVAL
29. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
30. SIGNATURE
LOGISTICS REVIEW
31. I HAVE REVIEWED THIS REQUEST AND RECOMMEND
APPROVAL
DISAPPROVAL
I CERTIFY THIS REQUEST IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. REQUESTED EQUIPMENT IS
ELIGIBLE FOR MEDCASE ACQUISITION.
32. TYPED NAME OF LOGISTICS CHIEF
33. SIGNATURE OF LOGISTICS CHIEF
ACTIVITY COMMANDER REVIEW
34. I HAVE REVIEWED THIS REQUEST AND RECOMMEND
35. EQUIPMENT REPLACED WILL BE
APPROVAL
DISAPPROVAL
TURNED IN
RETAINED
N/A
36. TYPED NAME OF ACTIVITY COMMANDER
37. SIGNATURE OF ACTIVITY COMMANDER
REGIONAL MEDICAL COMMAND (RMC) REVIEW
38. I HAVE REVIEWED THIS DOCUMENT AND RECOMMEND
39. RMC CONSULTANT ACTION CODE
APPROVAL
DISAPPROVAL
40. TYPED NAME OF RMC COMMANDER
41. SIGNATURE OF RMC COMMANDER
DA FORM 5028-R, JUL 1997
DA FORM 5028-R (TEST), NOV 81 IS OBSOLETE
APD LC v1.01ES
MEDCASE SUPPORT AND TRANSMITTAL FORM
For use of this form, see SB 8-75 MEDCASE; the proponent agency is the OTSG
1. ACTIVITY
2. ASSET CONTROL NUMBER
EQUIPMENT MAINTENANCE ACTIVITY
3. DO YOU SEE PROBLEMS WITH PROVIDING MAINTENANCE SUPPORT? (If Yes, explain)
YES
NO
4. MAINTENANCE WILL BE PROVIDED
5. ANNUAL MAINTENANCE COST
6. TRAINING TYPE
IN-HOUSE
SERVICE CONTRACT
NONE
ONE TIME
RECURRING
7. REPLACED ITEM WITH MAKE AND MODEL
10. MCEL COST
11. EXPENDED COST
8. LIFE EXPECTANCY (Years)
9. DATE IN SERVICE (YYYYMM)
12. EQUIPMENT AND INSTALLATION CHARACTERISTICS
13. THE JUSTIFICATION PROVIDED HAS BEEN REVIEWED
AND THE STATEMENTS REGARDING MAINTENANCE
ROUTINE
REQUIRES INSTALLATION
COMPLEX
HAV E BEEN VERIFIED.
REQUIRES TURNKEY INSTALLATION
THE REPLACEMENT OF THE ITEM
IS
EXISTING EQUIPMENT REQUIRES DE-INSTALLATION
IS NOT SUPPORTED
ADDITIONAL ELECTRICAL SUPPORT OR EMERGENCY POWER
BASED UPON MAINTENANCE CONSIDERATIONS.
14. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
15. SIGNATURE
ENGINEER (Health Facility Project Officer for BLIC NF & MB)
16. ARE SITE MODIFICATIONS, UTILITIES OR
17. ESTIMATED SITE PREPARATION COSTS
18. WITHIN THE SCOPE OF THE
OTHER COSTS INVOLVED?
PROJECT (BLIC NF OR MB)?
YES
NO
YES
NO
19. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
20. SIGNATURE
INFORMATION MANAGEMENT OFFICER
21. I HAVE REVIEWED THIS DOCUMENT AND RECOMMEND
APPROVAL
DISAPPROVAL
N/A
22. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
23. SIGNATURE
RESOURCES MANAGEMENT OFFICER
24. NON-MEDCASE COSTS ASSOCIATED WITH THIS REQUIREMENT ARE
25. THE ECONOMIC CONSIDERATIONS CITED
WITHIN CURRENT OR ANTICIPATED RESOURCES OF THIS ACTIVITY?
(In Justification) HAVE BEEN VERIFIED AND ARE
ACCURATE?
YES
NO
YES
NO
26. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
27. SIGNATURE
RADIOLOGY REVIEW
28. I HAVE REVIEWED THIS DOCUMENT AND RECOMMEND (Comments attached)
APPROVAL
DISAPPROVAL
29. TYPED NAME AND TITLE OF REVIEWING OFFICIAL
30. SIGNATURE
LOGISTICS REVIEW
31. I HAVE REVIEWED THIS REQUEST AND RECOMMEND
APPROVAL
DISAPPROVAL
I CERTIFY THIS REQUEST IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. REQUESTED EQUIPMENT IS
ELIGIBLE FOR MEDCASE ACQUISITION.
32. TYPED NAME OF LOGISTICS CHIEF
33. SIGNATURE OF LOGISTICS CHIEF
ACTIVITY COMMANDER REVIEW
34. I HAVE REVIEWED THIS REQUEST AND RECOMMEND
35. EQUIPMENT REPLACED WILL BE
APPROVAL
DISAPPROVAL
TURNED IN
RETAINED
N/A
36. TYPED NAME OF ACTIVITY COMMANDER
37. SIGNATURE OF ACTIVITY COMMANDER
REGIONAL MEDICAL COMMAND (RMC) REVIEW
38. I HAVE REVIEWED THIS DOCUMENT AND RECOMMEND
39. RMC CONSULTANT ACTION CODE
APPROVAL
DISAPPROVAL
40. TYPED NAME OF RMC COMMANDER
41. SIGNATURE OF RMC COMMANDER
DA FORM 5028-R, JUL 1997
DA FORM 5028-R (TEST), NOV 81 IS OBSOLETE
APD LC v1.01ES

Download DA Form 5028-R Medcase Support and Transmittal Form (Lra)

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